照顧一位頭部外傷導致顱內出血患者之護理經驗

Nursing Care of a Patient with Traumatic Intracranial Hemorrhage

柯亦芳(Yi-Fang Ke) ； 游顯妹(Hsien-Mei Yu)

《中山醫學雜誌》 22卷2期 (2011/06) Pp. 253-262

https://doi.org/10.30096/CSMJ.201106.0012

摘要

本篇個案是協助一位因交通事故傷害造成頭部外傷而導致顱內出血的男性病患，在接受緊急手術治療後，合併有顱內壓上升及因顱內出血產生神經功能後遺症，導致肢體活動障礙及害怕失去身體控制功能，而產生無力感之護理過程。照護期間為2008年7月18日至8月9日，藉由直接照護、會談、觀察等方法收集資料，運用羅氏適應模式進行整體性評估，評估結果發現個案有顱內調適能力降低、呼吸道清除功能失效與無力感等護理問題。針對這些問題，給予頭頸固定正中擺位促進腦部靜脈回流、執行侵入性治療或護理活動時，維持氧合，及配合降低顱內壓藥物的使用以預防顱內壓上升；給予胸部物理治療、促進排痰及定時抽痰，維持呼吸道通暢；提升自我照顧能力及提供疾病相關資訊，增進自我控制感與自信心，讓個案能以積極正向的態度，面對未來的復健療程。

關鍵字

頭部外傷 ； 無力感 ； 顱內出血

並列摘要

This article describes the nursing experience caring for a male traffic accident victim suffering from intracranial hemorrhage. The patient was found to have increased intracranial pressure and neurological sequelae, resulting in limb movement disorder and a sense of powerlessness and fear over loss of body control. The nursing period was from July 18 to August 9, 2008. Using Roy Adaptation Model, data were collected from direct attendance, observation and interview with the patient. The patient was found nursing problems: decreased intracranial adaptive capacity, ineffective airway clearance, and a sense of powerlessness. The patient received with head/neck fixation to promote cerebral venous return, invasive treatment maintenance of oxygenation with intracranial pressure lowering drugs to prevent increased intracranial pressure, chest physiotherapy to facilitate expectoration, and periodic phlegm suction. The patient was counseled on how to care for himself and provided relevant information on the disease in order to increase his sense of self-control and confidence. This was deemed necessary in order to empower him to participate actively in his future rehabilitation program.

並列關鍵字

head injury ； powerlessness ； intracranial hemorrhage